Part 1 of this form is a power of attorney for health care. Part 1 lets you name another individual as agent to make health-care decisions for you if you become incapable of making your own decisions or if you want someone else to make those decisions for you now even though you are still capable. You may also name an alternate agent to act for you if your first choice is not willing, able or reasonably available to make decisions for you. Unless related to you, your agent may not be an owner, operator or employee of a residential long-term health-care institution at which you are receiving care.

Unless the form you sign limits the authority of your agent, your agent may make all health-care decisions for you. This form has a place for you to limit the authority of your agent. You need not limit the authority of your agent if you wish to rely on your agent for all health-care decisions that may have to be made. If you choose not to limit the authority of your agent, your agent will have the right to:

(a) Consent or refuse consent to any care, treatment, service or procedure to maintain, diagnose or otherwise affect a physical or mental condition;

(b) Select or discharge health-care providers and institutions;

(c) Approve or disapprove diagnostic tests, surgical procedures, programs of medication and orders not to resuscitate; and

(d) Direct the provision, withholding or withdrawal of artificial nutrition and hydration and all other forms of health care, including life-sustaining treatment.

Part 2 of this form lets you give specific instructions about any aspect of your health care. Choices are provided for you to express your wishes regarding the provision, withholding or withdrawal of treatment to keep you alive, including the provision of artificial nutrition and hydration, as well as the provision of pain relief. Space is also provided for you to add to the choices you have made or for you to write out any additional wishes.

Part 3 of this form lets you express an intention to donate your bodily organs and tissues following your death.

Part 4 of this form lets you designate a physician to have primary responsibility for your health care.

Part 5 of this form lets you designate your Health Insurance Portability and Accountability Act of 1996 ("HIPAA) personal representative.  This Health Care Proxy Declaration is required for your Agent to access all of your HIPAA-protected health information, medical and hospital records, to execute authorizations to obtain such information and to consent to the disclosure of such information on your behalf.

Part 6 of this of this form  is an indemnity and hold harmless agree that protects your Agent for Health Care and any person or entity acting in reliance of your Agent's directions under this instrument from later claims by your heirs or the personal representative or executor of your (decedent's) estate.

Part 7 of this form provides guidance respecting interpretation of the format of the document and further provides that an attested copy of the document shall have the same effect as the original.

After completing this form, sign and date the form at the end. You must have 2 other individuals sign as witnesses. Although not an essential requirement in most states for the validity of your document, you should also have your document notarized.  Give a copy of the signed and completed form to your physician, to any other health-care providers you may have, to any health-care institution at which you are receiving care and to any health-care agents you have named. You should talk to the person you have named as agent to make sure that he or she understands your wishes and is willing to take the responsibility.

You have the right to revoke this advance health-care directive or replace this form at any time.

(1) DESIGNATION OF AGENT: I designate the following individual as my agent to make health-care decisions for me:

OPTIONAL: If I revoke my agent's authority or if my agent is not willing, able or reasonably available to make a health-care decision for me, I designate as my first alternate agent:

OPTIONAL: If I revoke the authority of my agent and first alternate agent or if neither is willing, able or reasonably available to make a health-care decision for me, I designate as my second alternate agent:

(2)  SUCCESSION OF AGENTS:  If I revoke the authority of my Agent, or if for any reason my Agent in not willing, able or reasonably available to act, my alternate agents, in the order so designated above, may prepare an affidavit certifying that my Agent, and my first alternate agent, as the case may be, has ceased or has become unable to serve as an agent hereunder and affix such affidavit to this document.  Insofar as third parties are concerned, an attested copy of an original of an affidavit executed pursuant to the foregoing provisions of this instrument shall be conclusive evidence of the facts set forth therein; and any person, firm or corporation acting or relying upon an original or attested copy of this instrument, whether or not it has attached thereto any such affidavit, shall incur no liability to me or to my estate because of such reliance.

(3) AGENT'S AUTHORITY:   I authorize my Agent to make all health-care decisions for me, and to do and perform all acts, matters or things whatsoever in connection therewith as fully in every respect as I, myself, could if personally present and competent,  including, without limitation, any and all of the following:

To consent to the provision to me by any person, persons, firm or corporation of medical care of any kind; to have access to any and all of my medical or clinical records and have authority to authorize release of such information to appropriate persons to ensure the continutiy of my health care; to select or discharge health care providers and institutions; to authorize my transfer and admission to or from a health care facility; to approve or disapprove diagnostic tests, surgical procedures, programs of medication and orders not to resuscitate; to consent or refuse to consent to the provision of any such medical care to me by an person, firm or corporation and to order the discontinuance of any medical care being rendered to me at any such time; and to make all health care decisions for me, including decisions to provide, withhold or withdraw artificially administered nutrition and hydration, except as I state here: .

I intend that my agent be treated as I would be treated with respect to my rights regarding the use and disclosure of my individually identifiable health information or other medical records, including without limitation any information governed by the Health Insurance Portability and Accountability Act of 1996, 42 U.S.C. §1320d, and regulations thereunder, C.F.R. §160-164. To this end, I authorize:

any physician, health-care professional, dentist, health plan, hospital, clinic, laboratory, pharmacy or other covered health-care provider, any insurance company and the Medical Information Bureau, Inc. or other health-care clearing house that has provided treatment or services to me, or that has paid for or is seeking payment from me for such services, to give, disclose and release to my Agent, without restriction, all of my individually identifiable health information and medical records regarding any past, present or future medical or mental health condition, including all information relating to the diagnosis and treatment of HIV/AIDS, sexually transmitted diseases, mental illness, and drug or alcohol abuse.

The foregoing rights to my medical information given to my Agent shall supersede any prior agreement that I may have made with my respective health-care providers, or any of them, to restrict access to or disclosure of my individually identifiable health information.  The foregoing rights to my medical information given to my Agent have no expiration date and shall expire only in the event that I revoke this authority in writing and deliver such revocation to my health-care provider.

(4) WHEN AGENT'S AUTHORITY BECOMES EFFECTIVE: My agent's authority becomes effective when my primary physician determines that I am unable to make my own health-care decisions unless I place my initials HERE: (PPP). If my initials appear above, my agent's authority to make health-care decisions for me takes effect immediately.

(5) AGENT'S OBLIGATION: My agent shall make health-care decisions for me in accordance with this power of attorney for health care, any instructions I give in Part 2 of this form and my other wishes to the extent known to my agent. To the extent my wishes are unknown, my agent shall make health-care decisions for me in accordance with what my agent determines to be in my best interest. In determining my best interest, my agent shall consider my personal values to the extent known to my agent.

(6) NOMINATION OF GUARDIAN: If a guardian of my person needs to be appointed for me by a court, I nominate the agent designated in this form. If that agent is not willing, able or reasonably available to act as guardian, I nominate the alternate agents whom I have named, in the order designated.  My Agent shall also have the power to nominate and appoint a conservator, who may be my Agent, of my estate if the need should arise

(7)  MISCELLANEOUS PROVISIONS:  If, pursuant to the terms hereof, there is at any time more than one person acting on my behalf hereunder, whether as my Agent or as agent for my Agent, I reserve the right to revoke any grant of authority made as to one such person without revoking it as to any other person acting hereunder; and the death of any such person, whether an agent named herein or a person appointed by an agent named herein or a person to whom authority has been delegated by an agent named herein or by another, shall not operate to terminate the authority of any other person acting hereunder.  Except to the extent any power of attorney executed by me hereafter provides to the contrary by specific reference to this instrument and the date of its execution, this power of attorney for health care shall not prejudice or be affected by any other powers of attorney granted heretofore or hereafter, it being my intention, absent any such specific reference, that the powers granted by any such other instrument and by this instrument may be exercised concurrently.

If you are satisfied to allow your agent to determine what is best for you in making end-of-life decisions, you need not fill out this part of the form. If you do fill out this part of the form, you may strike any wording you do not want.

(8) END-OF-LIFE DECISIONS: I direct that my health-care providers and others involved in my care provide, withhold or withdraw treatment in accordance with the choice I have made between choice (a) and choice (b) below:

(a) Choice Not To Prolong Life: I do not want my life to be prolonged if (i) I have an incurable and irreversible condition that will result in my death within a relatively short time, (ii) I become unconscious and, to a reasonable degree of medical certainty, I will not regain consciousness, or (iii) the likely risks and burdens of treatment would outweigh the expected benefits, OR

(b) Choice To Prolong Life: I want my life to be prolonged as long as possible within the limits of generally accepted health-care standards.

My choice of the above two alternatives is (a).

(9) ARTIFICIAL NUTRITION AND HYDRATION: Artificial nutrition and hydration must be provided, withheld or withdrawn in accordance with the choice I have made in paragraph (6) unless I include my initials HERE: (PPP, hydration only). If I entered my initials in this sub-paragraph (9), artificial nutrition and/or hydration must be provided regardless of my condition and regardless of the choice I have made in paragraph (6).  If I have chosen that hydration be administered to me but not nutrition, I have added in the appropriate area herein the words "hydration only" in addtition to my initials.

(10) RELIEF FROM PAIN: I direct that treatment for alleviation of pain or discomfort be provided or not provided as follows: provide treatment.

If I have chosen that treatment for alleviation of pain or discomfort be provided, I direct that such treatment be provided at all times, even if it hastens my death.

(11) OTHER WISHES: (If you do not agree with any of the optional choices above and wish to write your own, or if you wish to add to the instructions you have given above, you may do so here.) I direct that: .

(12) CHOICE RESPECTING ORGAN DONATION: Upon my death, my desire respecting donation of my organs, tissues or parts is indicated as follows:

(a) Do I wish to donate my organs, tissues or body parts? Yes.

If my choice above was that I do so wish to donate, my choice is further described as follows:

(b) Do I wish to make an unrestricted gift of ALL or ANY needed organs, tissues or parts? No.

(c) I wish to give ONLY the following organs, tissues or parts: corneas, heart, lungs, liver, kidneys.

If I chose to donate my organs, tissues or parts, my gift can be used only for the following purposes: transplants only.

(13) DESIGNATION OF PRIMARY CARE PHYSICIAN: I designate the following physician as my primary physician:

OPTIONAL: If the physician I have designated above is not willing, able or reasonably available to act as my primary physician, I designate the following physician as my primary physician: